Republic Companies - » HMH7 CONTRACTOR SPIFF UNIVERSAL FORM

USE THIS FORM TO CLAIM YOUR YORK OR LUXAIRE HMH7 BONUS SPIFF NOW THROUGH JANUARY 31, 2023.

All claims must be submitted by February 28th, 2023.

Note: A valid W-9 is required for payment. You can send a copy of your W-9 to your Republic Territory Manager, or email an electronic copy to [email protected]

Download W-9 Form

HMH7 CONTRACTOR SPIFF UNIVERSAL FORM

Dealer Name:(Required)

Email Address:(Required)

Salesperson Name:(Required)

SYSTEM 1

Heat Pump Model(Required)

Heat Pump Serial Number(Required)

Check the box below to confirm installation is in a Residential application(Required)

I confirm installation is in a Residential application

Installation Date(Required)

Homeowner Name(Required)

Installation Address(Required)

City

State

Zip code

SYSTEM 2

Heat Pump Model

Heat Pump Serial Number

Check the box below to confirm installation is in a Residential application

I confirm installation is in a Residential application

Installation Date

Homeowner Name

Installation Address

City

State

ZIP code

SYSTEM 3

Heat Pump Model

Heat Pump Serial Number

Check the box below to confirm installation is in a Residential application

I confirm installation is in a Residential application

Installation Date

Homeowner Name

Installation Address

City

State

Zip code

SPIFF PAYMENT INFORMATION

Has this equipment been registered for warranty on HVAC Navigator?(Required)

Yes

All equipment must be registered in order to qualify for spiffs.

Total Spiff Amount(Required)

Check the box below to confirm you have submitted a valid W-9 form to your Republic Territory Manager or emailed to [email protected](Required)

I have submitted a W-9 form

This field is for validation purposes and should be left unchanged.